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The aid of bacteriology in sanitary administration
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T H E AID OF B A C T E R I O L O G Y IN S A N I T A R Y ADMINISTRATION? ~: BY J. COOTE HIBBERT, M.D. (Loud.), ~.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health, Warrington. Y only excuse for bringing before you M the points raised in this short paper is that I hope to promote a discussion on a subject which is of considerable importance in public health work, b u t which nevertheless does not always receive the attention it has a righ.t to claim. An acquaintance with the sanitary administration of several towns has shown me that medical officers of health appeal to bacteriology in very different degrees, and it is with the object of suggesting a greater lmiformity in this respect, and especially of urging that bacteriology should have a more important place allotted to it in the routine work of each health department that I venture to submit to you the following remarks. It is only within comparatively recent times that bacteriology has come to the forefront as an ally of hygiene, and there are still some who refuse to recognise its claim, or who are at least sufficiently conservative to hesitate in invoking its aid to any extent in their public health work. Sometimes, even at meetings of this Society, we still hear the sceptic raise his voice, and even if doubts are not expressed as to the existence of such a well-known organism as the diphtheria baeilhs, it is at times questioned whether the bacillus is the cause of the disease we know as diphtheria. I am not, however, going to raise a discussion on such fundmnental points as these, which I think almost everyone, who has any knowledge of tlie subject, admits are now settled. The chief question to be answered is to what extent we can hope at the present time to employ the science with practical benefit in our work, and how far we should induce our authorities to expend money on the investigations can'ied out at the bacteriological l a b o r a t o r y . At the same time that we are computing its definite practical value to us in our daily work, we must not forget the advantages that accrue to us as medical officers of health front our being in a position to pu.t more of our work, and especially that in connection with infectious disease, on a * R e a d at the M e e t i n g of i h e N o r t h - W e s t e r n Branch of the ~qociety of Medi( al Officers of Health on D e c e m b e r 18tiL 19~)8.
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scientific basis, and to argue authoritatively with .those laymen who think that they are quite as capable of dealing with public health questions as the medical officer they have appointed as their guide. Further, the accumulated results of investigations carried out on scientific lines b y all sanitary authorities throughout the country into outbreaks of infectious disease and into the bacterial condition of such known diseasecarriers as milk and water, Mthongh perhaps in some instances, not serving any obvious pro'pose at the time, nmst tend eventually to the advancement of knowledge and to improved methods of sanitary administration. In the first place we will deal with bacteriology in its relation to infectious disease. Most sanitary authorities, I believe, make some attempt at offering facilities to the medical practitioner for the examination of specimens for the diagnosis of diphtheria, enteric fever and tuberculosis ; but even these facilities are often proffered in a somewhat half-hearted manner and are certainly very often received by the medical practitioner with still less enthusiasm. When one considers the difficulty there is in diagnosing the pathological condition in any ease of sore throat, it is a matter for surprise, as well as for regret, that advantage is not taken more often of this aid to confirming a diagnosis of diphtheria, or to excluding the disease. It is doubtless the not infrequent experience of many of us to hear of a patient who has been treated for simple tonsilitis, eventnallyshowing symptoms of diphtheritic paralysis; and as probably there has been no thought of isolating these eases from the general public, the chance of their having spread infection is very considerable, in like manner obscure cases of continued fever are often treated for weeks with merely provisional diagnosis and without any thought of appeal to the agglutination reaction. It is also no uncommon occurrence for laryngeal cases of diphtheria to be overlooked, especially if, as very often happens, there is no evident disease on the fauces. I have repeatedly .found that medical practitioners hesitate to pronounce such eases to be of a diphtheritic nature on account of the absence of visible membrane, and for the same reason they consider it to be useless to take a swabbing from the throat for examination. The bacilli are, however, nearly always to be
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detected in the faucial secretions of such cases, and it is very important that a bacteriological examination should not be omitted because the fauces present a healthy appearance. As regards notified eases of diphtheria, it would certainly be a great advantage, frmn a public health point of view, if a confirmatory bacteriological examination were made in all instances; b u t on the other hand, neither notification nor treatment should be delayed for the result of the investigation, as only a series of negative results would tend to e x e h d e a diagnosis of diphtheria where the clinical symptoms pointed to that disease. Without this confirmatory examination, the value of ore: diphtheria statistics is much discounted, and our knowledge of the true origin Of this disease, which pays no heed to the advancement of general sanitation, progresses b u t slowly. Desirable as it i s t o be certain of the nature of notified cases, it is far more important that cases of sore throat which do not present the generally accepted clinical signs of diphtheria should be examined, for there is no doubt that many of these are mild attacks of that disease. Of course a large proportion of these patients will not come under the notice of a medical practitioner or of the health departlnent ; but, at any rate, those children who are absent from school on account of sore throat can be reported to the medical ottieer of heaRh, and any suspicious throats swabbed before the children are allowed to return. Another very important point as regards diphtheria is the determination in any instance of the end of infectivity, and this cannot be settled without an appeal to the laboratory. At nearly all fever hospitals patients are not discharged until one or more examinations have failed to show the presence of remaining bacilli, b u t unfortunately the same preeautim~ is seldom taken by the medical practitioner before he sets his patient free. In face of the general increase in the prevalence of the disease in this country, the omission of this very simple safeguard is much to be regretted, especially as these patients are often declared to be free from infection soon after the local lesion has cleared up, and generally b y the end of three weeks, while on the other hand a bacteriological examination often shows the bacilli to persist for weeks longer. The medical officer of health can meet this danger in one direction, for he now has considerable
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control over school children and can obtain a swabbing from their throats before allowing their return to school. The d e a l i n g w i t h diphtheria contacts is now another very important part of our work, and makes a considerable demand on the laboratory. The contacts who recluire our (-hief attention are again school children, and with our present knowledge we should certainly forbid their retm'n to school from a house where there has been a ease of diphtheria, unless a bacteriological examination of their throats has given a negative result. I have systematically examined such children at Warrington and have found a considerable number to have the Klebs-Lhflter bacilli in their fauces, although there was no naked eye evidence of disease. In several instances contacts who had been excluded from school have developed clinical signs of diphtheria a few days after their throats had been examined and bacilli found to be present. As regards typhoid fever and its allies--the paratyphoid fevers--we have the undoubted help in diagnosis w h i c h is afforded by the agglutination test, and it is now recognised that many cases, which resemble typhoid fever clinically, b u t which fail to supply a serum that will agglutinate typhoid bacilli, are instances of one of the paratyphoid fevers, and the blood of these patients will be found to e h m p the corresponding paratyphoid bacilli. I had recently two interesting examples of this paratyphoid disease in the fever hospital at Warrington. A. patient who travelled about in a caravan was admitted suffering from a disease which resembled typhoid fever in its clinical aspects, b u t the blood of the patient in dilution of 1 in 50 failed on several occasions to give the agglutination test with the b a e i l h s typhosus. Owing to two relapses, the patient's illness was protraeted, and after a few weeks one of the nurses Who attended the ease was taken ill. The nurse presented symptoms of typh(~id fever, b u t her blood in a d i h t i o n of 1 in 50 also failed to clump typhoid bacilli. Subsequently, I o b t a i n e d cultnres of b a c i l h s paratyphosus alpha and beta, and the latter bacilli were readily clumped b y the blood of both patients in dilutions of 1 in 50. At the present time probably little is done in the way of examining the fveces and urine of convalescent typhoid patients, b u t the recent information as to the persistence of
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infection in the excreta of certain persons who have suffered from the disease will probably cause such examinations to be undertaken more often, especially as regards persons who are occupied in the handling or preparation of human food. The speeifi~ natm'e of certain seclne]m of typhoid fever, such as inflammatory conditions of bone, etc., must also be remembered, and the possible presence of typhoid bacilli in any resulting discharges investigated. Unfortunately at present we derive little help from bacteriology as regards scarlet fever, but in connection with tuberculosis and some other less eommon infectious diseases such as cere bro-spinal fever, plague, cholera, anthrax, and glanders, we can obtain much assistance from the bacteriological laboratory. Inseparable from the subject of infectious disease is the question of disinfectants. Here, again, we have neglected the application of bacteriology to a surprising extent; so much so that our chemists are leading the obvious way in the matter. I have already protested against this bacteriological work (for the investigation of disinfectants is now almost entirely a matter for the bacteriologist) leaving medical hands ; b u t I am afraid we "]Lave only ourselves to blame in this respect, for we have been slow to investigate the subject scientifically and, as Dr. Barlow pointed out in a recent paper, have accepted with far too implicit faith the uncorroborated statements of the manufacturers as to the efficacy of the so-called disinfectant preparations that are being used b y the public and ourselves. To nay mind we ean now ascertain with some degree of accuracy what disinfectants are the most efficient under each special set of conditions, and we should therefore banish from our use all that are inefficient. In the first place, we can determine the relative germicidal power of the various disinfectants compared with that of a standard substance according to the method for which we have to thank those well&nown chemists, Dr. Rideal and Mr. Ainsley Walker. This method affords fairly definite knowledge of the action of any preparation on the naked germ, and also supplies a test as to whether a disinfectant is being kept up to a standard which may be guaranteed b y the manufacturer. Secondly, we can further test experimentally the action of the preparation on special germs under conditions resembling as far as possible those which obtain in the practical use to
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which we desire the disinfectant to be put. It is, of course, these latter tests which will enable ns to decide as to what disinfectants to use in our practical w o r k ; while the former tests by the R.ideal- Walker method wilt chiefly be useful in determining whether or no the disinfectant is kept up to the standard guaranteed. If an authoritative body of experts, unassociated in any way with the manufacturers, were appointed b y Government to investigate the matter and to indicate what disinfectants are most efficient ~mder various eiremnstanees , the need for each authority carrying out these experiments, except for special purposes, would be obviated. I now come to an important tale played b y bacteriology in pnblie health work, namely, that of guardian over our water and milk supplies. In connection with the water supply, there can, I think, be no doubt that we should obtain regular and frequent bacteriological examinations, especially with reference to the presence of B. cell, for such examinations are a more delicate test of sewage pollution than the chemical a n a l y s e s which they should supplement rather than replace. There are, even experts on the subject admit, many difficulties in the interpretation of the r e s u l t of a bacteriological examination of a water sample, and hard and fast standards as to what in this respect is a satisfactory, and what an unsatisfactory, water are now generally deprecated. Nevertheless, systematic examinations over a certain period will enable a standard to be fixed for any particular supply, and variations from this standard will then be readily apparent and speeial pollution at once detected. Further, when this standard has been ascertained for any water supply, a check can be kept on tile efficieney of any method of purification which nmy be adopted. As regards the milk supply of a town, nnder the p r e s e n t conditions of sanitary control, we are unable to take full advantage of the help we should obtain from bacteriology. If it were made compulsory for dairy farmers and milk dealers to cool milk down below a certain temperature immediately after its collection, and to keep it at a low temperature during its transit and storage, the enumeration of the number of organisms
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per c.e., and especially of B. eoZi, would give some indication of the amount of added dirt of a harmful nature ; but we cannot make use of this guide as to the cleanliness that has been observed in the dealing with milk that has not been cooled down, for organisms multiply with great rapidity in such an excellent culture medium. Investigations into the baeterial content of milk samples have, however, shown the very unsatisfactory condition o[ the greater part of this important food, and have indicated that far greater care is required in its collection and storage. The chief bacteriological procedure in conneetion with milk is the examination for tubercle baeilli; but the detection of this bacillus in any sample of milk is often of less value to the health authority than is at first sight expected, and of ;less help than if we had further powers in connection with dairy farms. In the first plaee we have to wait at least three or four weeks from the time of taking the smnple before the result of the examination is obtained--unless the bacilli happen to be detected by direct microscopic examination of the eentrifngalised milk. Secondly, if the milk prove to be tuberculous and, after following the supply back to the dairy farm, we examine (in company with a veterinary surgeon) the herd, and pick out suspicious cows, there is a fm'ther delay. We have now to obtain tile veterinary surgeon's certificate that the suspected cow or cows have tubercular disease of the udder, and it is seldom in m y experience that he will give such a certificate unless another sample of nfilk from the udder in question has been proved to contain the bacilli, entailing another delay of probably three to four weeks before we can stop the milk supply from the cows in question. The difficulty of dealing immediately with suspected cows, when the mixed milk from the dairy farm has been found to be tubereulous, greatly minimises at the present time the practical value of bacteriology in this respect. Nevertheless, this work in connection with milk has brought to light the serious extent to which milk is infected with tubercle bacilli, and h a s played its part in hurrying on the shortly expected legislation which wilt doubtless d e a l w i t h tile question at its origin, namely, at the dairy farm. ~ a n y of the dark and insanitary cowsheds must be thoroughly infected with the bacilli given
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o[~ by generations of tuberculous cows, and it is quite conceivable that milk conning from such premises may be infected, not only from any of the diseased cows that are being milked, but also from dust, etc., which happens to be floating about in the cowshed during the milking process. This very probable source of the tubercle bacilli in the dust of the present insanitary cowsheds is often overlooked, and the search for the origin of tile bacitli which have been detected in the mixed supply Dora a dairy farm is too often limited to the cows producing the inilk. In addition to its aid in the foregoing investigations which comprise the greater part of municipal bacteriology, the laboratory will assist us in diagnosing certain diseases of cattle, such as anthrax and tuberculosis, and wi]l he]p ore" enquiries into diseased conditions of food and into outbreaks of food poisoning. I have thus attempted to outline very briefly the chief practical applications of bacteriologT at the present time in public health work. These uses of the science are, of course, well known to all of us, b u t - - a n d this is my chief point--we do not in my opinion sufficiently encourage this branch of our work which, as a matter of fact, is the seientifie basis on which a large part of our sanitary administration rests. In order to adequately make use of bacteriology, each health department should have its own laboratory which should be looked upon as an essential part of the department; and in these laboratories, even in the smaller towns, the necessary investigations should be carried out, except perhaps such as require the inoculation of animals. Unless this obtains, the expense incurred by sending specimens to be examined at some independent laboratory will prevent the extended application of this branch of our work. In the smaller towns, where there may not be sufficient'work for a whole-time bacteriologist, the laboratory can be located at the fever hospital and, if the medical officer of health has not the time to do tlm work himself, the resident at the hospitM or the assistant medical officer of health should also act as bacteriologist. The advantage which the medicM officer of health derives front having a well-equipped laboratory elose at hand, and from his being able to investigate any doubtful ease of infectious disease both clinically and in the laboratory, is evident; and only {,hose
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who thus personally see both sides of the picture can fully appreciate the value of the agglutination reaction or the futility of attempting to diagnose diphtheria without a bacteriological investigation. For the past four or five years, during which I have been connected with infectious disease hospitals, I have made a practice of investigating eases of diphtheria and enteric fever both at the bedside and in the laboratory, and it has ])een a rare occurrence for the bacteriological results to be negatived by the subsequent course of the illness. D u e c a r e must of necessity be exercised in taking the specimens for examination, and carelessness in this procedure will in great part account for many failures in detecting the bacilli in swabbings from throats of diphtheritic patients. Instances, too, where the blood of patients, suffering from apparently typical attacks of typhoid fever, has failed to give the agglutination test with typhoid bacilli, may now be explained on the ground that these were infections b y the b a c i l h s Paratyphosus and not by the bacillus Typhosus, and consequently the blood would have given a positive reaction if tested against the former bacillus. One cannot make a routine examination of diphtheria convalescents without being struck b y the number of eases which continue to harbour the bacilli in their throats for a considerable time longer than three weeks; and when one considers that home treated cases are rarely isolated longer than three weeks, it is evident that we cannot hope to deal satisfactorily with diphtheria so long as the medical practitioner fails to make use of bacteriology to determine the end of infectivity. In like manner, if we are to grapple at all effectively with this disease, we m u s t see that cases of sore throat are more fully investigated and that a routine bacteriological examination of contacts is made. In this paper I have chiefly referred to the pifblic health side of the subject, and especially to the increased protection which would be afforded to the general public by a more extended use of bacteriology. While this aspect of the question is perhaps the one which concerns the medical officer of health the more closely, t h e r e i s also the patient's interest to be considered. Th.erapeutie sera, which at the present day are among our most potent remedies, require for their successful application that an early and definite diagnosis should
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be made, and it is fully proved b y statistics that the administration of antitoxins is the more suecessfill the eai'lier it is undertaken, and that delay in tile use of the remedy carries with it proportional loss for the patient of the advantages offered by this line of treatment. Hence, for this reason also, it is very necessary that means for an innnediate bacteriological examination ef any suspected case should be within easy reach. Then only will the practitioner make full use of the laboratory, and then only shall we be able to complain if he still neglects to avail himself of it. At the present time not only does the general public suffer through being often exposed to the infection of nndiagnosed cases of infectious disease, b u t the patient also suffers front the delay in rec.eiving suitable treatment. We have also a fiehl for work in studying the special germs of our own districts, for doubtless t h e r e are variations of the stone bacillus in different localities, and an antitoxin which is successful against the toxins furnished by the strain of bacillus found in one district may not equally succeed against those of the somewhat modified bacillus flourishing in another part of the country. In m y own experience, for example, diphtheria does not respond to the action of antitoxin in the north of England to the same extent as in the south; and the same difference in the disease is shown by statistics, for while the case mortality rate in the northern towns ranges at about 20 per cent. or more, that for the southern towns averages little over 12 per cent. In' conehsion, I would suggest that, with a little more scientific investigation on the part of the various health departments, many important everyday questions, such as whether drain or sewer air is ever found to convey the germs of diphtheria and typhoid fever, may be more definitely settled, and that we may then be able -to speak from the results of our practical, experiments instead of mereiy expressing pious opinions on the subject. MmWlW~S' ACT UO~t~IITTEE.--The Departmental Committee appointed by the Lord President of the Council to consider the working" of the Midwives' Act, held its sixth meeting on March 10th at the Privy Council Office, Mr. Almerie FitzRoy presiding. The following witnesses :~ttended and gave evidence : Sir George t~ordham, the Treasurer of the Central Midwives Board, and ret)resentative of the County Councils Association; l)r. A. Robinson, Medical Officer of Health for the County Borough of Rotherham ; and Mrs. Heywood Johnstone, President of t,he Rural Midwives Association.
PUBLIC H E A L T H .
T H E AID OF B A C T E R I O L O G Y IN S A N I T A R Y ADMINISTRATION? ~: BY J. COOTE HIBBERT, M.D. (Loud.), ~.R.C.S., L.R.C.P., D.P.H., Medical Officer of Health, Warrington. Y only excuse for bringing before you M the points raised in this short paper is that I hope to promote a discussion on a subject which is of considerable importance in public health work, b u t which nevertheless does not always receive the attention it has a righ.t to claim. An acquaintance with the sanitary administration of several towns has shown me that medical officers of health appeal to bacteriology in very different degrees, and it is with the object of suggesting a greater lmiformity in this respect, and especially of urging that bacteriology should have a more important place allotted to it in the routine work of each health department that I venture to submit to you the following remarks. It is only within comparatively recent times that bacteriology has come to the forefront as an ally of hygiene, and there are still some who refuse to recognise its claim, or who are at least sufficiently conservative to hesitate in invoking its aid to any extent in their public health work. Sometimes, even at meetings of this Society, we still hear the sceptic raise his voice, and even if doubts are not expressed as to the existence of such a well-known organism as the diphtheria baeilhs, it is at times questioned whether the bacillus is the cause of the disease we know as diphtheria. I am not, however, going to raise a discussion on such fundmnental points as these, which I think almost everyone, who has any knowledge of tlie subject, admits are now settled. The chief question to be answered is to what extent we can hope at the present time to employ the science with practical benefit in our work, and how far we should induce our authorities to expend money on the investigations can'ied out at the bacteriological l a b o r a t o r y . At the same time that we are computing its definite practical value to us in our daily work, we must not forget the advantages that accrue to us as medical officers of health front our being in a position to pu.t more of our work, and especially that in connection with infectious disease, on a * R e a d at the M e e t i n g of i h e N o r t h - W e s t e r n Branch of the ~qociety of Medi( al Officers of Health on D e c e m b e r 18tiL 19~)8.
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scientific basis, and to argue authoritatively with .those laymen who think that they are quite as capable of dealing with public health questions as the medical officer they have appointed as their guide. Further, the accumulated results of investigations carried out on scientific lines b y all sanitary authorities throughout the country into outbreaks of infectious disease and into the bacterial condition of such known diseasecarriers as milk and water, Mthongh perhaps in some instances, not serving any obvious pro'pose at the time, nmst tend eventually to the advancement of knowledge and to improved methods of sanitary administration. In the first place we will deal with bacteriology in its relation to infectious disease. Most sanitary authorities, I believe, make some attempt at offering facilities to the medical practitioner for the examination of specimens for the diagnosis of diphtheria, enteric fever and tuberculosis ; but even these facilities are often proffered in a somewhat half-hearted manner and are certainly very often received by the medical practitioner with still less enthusiasm. When one considers the difficulty there is in diagnosing the pathological condition in any ease of sore throat, it is a matter for surprise, as well as for regret, that advantage is not taken more often of this aid to confirming a diagnosis of diphtheria, or to excluding the disease. It is doubtless the not infrequent experience of many of us to hear of a patient who has been treated for simple tonsilitis, eventnallyshowing symptoms of diphtheritic paralysis; and as probably there has been no thought of isolating these eases from the general public, the chance of their having spread infection is very considerable, in like manner obscure cases of continued fever are often treated for weeks with merely provisional diagnosis and without any thought of appeal to the agglutination reaction. It is also no uncommon occurrence for laryngeal cases of diphtheria to be overlooked, especially if, as very often happens, there is no evident disease on the fauces. I have repeatedly .found that medical practitioners hesitate to pronounce such eases to be of a diphtheritic nature on account of the absence of visible membrane, and for the same reason they consider it to be useless to take a swabbing from the throat for examination. The bacilli are, however, nearly always to be
1909.
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detected in the faucial secretions of such cases, and it is very important that a bacteriological examination should not be omitted because the fauces present a healthy appearance. As regards notified eases of diphtheria, it would certainly be a great advantage, frmn a public health point of view, if a confirmatory bacteriological examination were made in all instances; b u t on the other hand, neither notification nor treatment should be delayed for the result of the investigation, as only a series of negative results would tend to e x e h d e a diagnosis of diphtheria where the clinical symptoms pointed to that disease. Without this confirmatory examination, the value of ore: diphtheria statistics is much discounted, and our knowledge of the true origin Of this disease, which pays no heed to the advancement of general sanitation, progresses b u t slowly. Desirable as it i s t o be certain of the nature of notified cases, it is far more important that cases of sore throat which do not present the generally accepted clinical signs of diphtheria should be examined, for there is no doubt that many of these are mild attacks of that disease. Of course a large proportion of these patients will not come under the notice of a medical practitioner or of the health departlnent ; but, at any rate, those children who are absent from school on account of sore throat can be reported to the medical ottieer of heaRh, and any suspicious throats swabbed before the children are allowed to return. Another very important point as regards diphtheria is the determination in any instance of the end of infectivity, and this cannot be settled without an appeal to the laboratory. At nearly all fever hospitals patients are not discharged until one or more examinations have failed to show the presence of remaining bacilli, b u t unfortunately the same preeautim~ is seldom taken by the medical practitioner before he sets his patient free. In face of the general increase in the prevalence of the disease in this country, the omission of this very simple safeguard is much to be regretted, especially as these patients are often declared to be free from infection soon after the local lesion has cleared up, and generally b y the end of three weeks, while on the other hand a bacteriological examination often shows the bacilli to persist for weeks longer. The medical officer of health can meet this danger in one direction, for he now has considerable
2t~5
control over school children and can obtain a swabbing from their throats before allowing their return to school. The d e a l i n g w i t h diphtheria contacts is now another very important part of our work, and makes a considerable demand on the laboratory. The contacts who recluire our (-hief attention are again school children, and with our present knowledge we should certainly forbid their retm'n to school from a house where there has been a ease of diphtheria, unless a bacteriological examination of their throats has given a negative result. I have systematically examined such children at Warrington and have found a considerable number to have the Klebs-Lhflter bacilli in their fauces, although there was no naked eye evidence of disease. In several instances contacts who had been excluded from school have developed clinical signs of diphtheria a few days after their throats had been examined and bacilli found to be present. As regards typhoid fever and its allies--the paratyphoid fevers--we have the undoubted help in diagnosis w h i c h is afforded by the agglutination test, and it is now recognised that many cases, which resemble typhoid fever clinically, b u t which fail to supply a serum that will agglutinate typhoid bacilli, are instances of one of the paratyphoid fevers, and the blood of these patients will be found to e h m p the corresponding paratyphoid bacilli. I had recently two interesting examples of this paratyphoid disease in the fever hospital at Warrington. A. patient who travelled about in a caravan was admitted suffering from a disease which resembled typhoid fever in its clinical aspects, b u t the blood of the patient in dilution of 1 in 50 failed on several occasions to give the agglutination test with the b a e i l h s typhosus. Owing to two relapses, the patient's illness was protraeted, and after a few weeks one of the nurses Who attended the ease was taken ill. The nurse presented symptoms of typh(~id fever, b u t her blood in a d i h t i o n of 1 in 50 also failed to clump typhoid bacilli. Subsequently, I o b t a i n e d cultnres of b a c i l h s paratyphosus alpha and beta, and the latter bacilli were readily clumped b y the blood of both patients in dilutions of 1 in 50. At the present time probably little is done in the way of examining the fveces and urine of convalescent typhoid patients, b u t the recent information as to the persistence of
266
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infection in the excreta of certain persons who have suffered from the disease will probably cause such examinations to be undertaken more often, especially as regards persons who are occupied in the handling or preparation of human food. The speeifi~ natm'e of certain seclne]m of typhoid fever, such as inflammatory conditions of bone, etc., must also be remembered, and the possible presence of typhoid bacilli in any resulting discharges investigated. Unfortunately at present we derive little help from bacteriology as regards scarlet fever, but in connection with tuberculosis and some other less eommon infectious diseases such as cere bro-spinal fever, plague, cholera, anthrax, and glanders, we can obtain much assistance from the bacteriological laboratory. Inseparable from the subject of infectious disease is the question of disinfectants. Here, again, we have neglected the application of bacteriology to a surprising extent; so much so that our chemists are leading the obvious way in the matter. I have already protested against this bacteriological work (for the investigation of disinfectants is now almost entirely a matter for the bacteriologist) leaving medical hands ; b u t I am afraid we "]Lave only ourselves to blame in this respect, for we have been slow to investigate the subject scientifically and, as Dr. Barlow pointed out in a recent paper, have accepted with far too implicit faith the uncorroborated statements of the manufacturers as to the efficacy of the so-called disinfectant preparations that are being used b y the public and ourselves. To nay mind we ean now ascertain with some degree of accuracy what disinfectants are the most efficient under each special set of conditions, and we should therefore banish from our use all that are inefficient. In the first place, we can determine the relative germicidal power of the various disinfectants compared with that of a standard substance according to the method for which we have to thank those well&nown chemists, Dr. Rideal and Mr. Ainsley Walker. This method affords fairly definite knowledge of the action of any preparation on the naked germ, and also supplies a test as to whether a disinfectant is being kept up to a standard which may be guaranteed b y the manufacturer. Secondly, we can further test experimentally the action of the preparation on special germs under conditions resembling as far as possible those which obtain in the practical use to
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which we desire the disinfectant to be put. It is, of course, these latter tests which will enable ns to decide as to what disinfectants to use in our practical w o r k ; while the former tests by the R.ideal- Walker method wilt chiefly be useful in determining whether or no the disinfectant is kept up to the standard guaranteed. If an authoritative body of experts, unassociated in any way with the manufacturers, were appointed b y Government to investigate the matter and to indicate what disinfectants are most efficient ~mder various eiremnstanees , the need for each authority carrying out these experiments, except for special purposes, would be obviated. I now come to an important tale played b y bacteriology in pnblie health work, namely, that of guardian over our water and milk supplies. In connection with the water supply, there can, I think, be no doubt that we should obtain regular and frequent bacteriological examinations, especially with reference to the presence of B. cell, for such examinations are a more delicate test of sewage pollution than the chemical a n a l y s e s which they should supplement rather than replace. There are, even experts on the subject admit, many difficulties in the interpretation of the r e s u l t of a bacteriological examination of a water sample, and hard and fast standards as to what in this respect is a satisfactory, and what an unsatisfactory, water are now generally deprecated. Nevertheless, systematic examinations over a certain period will enable a standard to be fixed for any particular supply, and variations from this standard will then be readily apparent and speeial pollution at once detected. Further, when this standard has been ascertained for any water supply, a check can be kept on tile efficieney of any method of purification which nmy be adopted. As regards the milk supply of a town, nnder the p r e s e n t conditions of sanitary control, we are unable to take full advantage of the help we should obtain from bacteriology. If it were made compulsory for dairy farmers and milk dealers to cool milk down below a certain temperature immediately after its collection, and to keep it at a low temperature during its transit and storage, the enumeration of the number of organisms
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per c.e., and especially of B. eoZi, would give some indication of the amount of added dirt of a harmful nature ; but we cannot make use of this guide as to the cleanliness that has been observed in the dealing with milk that has not been cooled down, for organisms multiply with great rapidity in such an excellent culture medium. Investigations into the baeterial content of milk samples have, however, shown the very unsatisfactory condition o[ the greater part of this important food, and have indicated that far greater care is required in its collection and storage. The chief bacteriological procedure in conneetion with milk is the examination for tubercle baeilli; but the detection of this bacillus in any sample of milk is often of less value to the health authority than is at first sight expected, and of ;less help than if we had further powers in connection with dairy farms. In the first plaee we have to wait at least three or four weeks from the time of taking the smnple before the result of the examination is obtained--unless the bacilli happen to be detected by direct microscopic examination of the eentrifngalised milk. Secondly, if the milk prove to be tuberculous and, after following the supply back to the dairy farm, we examine (in company with a veterinary surgeon) the herd, and pick out suspicious cows, there is a fm'ther delay. We have now to obtain tile veterinary surgeon's certificate that the suspected cow or cows have tubercular disease of the udder, and it is seldom in m y experience that he will give such a certificate unless another sample of nfilk from the udder in question has been proved to contain the bacilli, entailing another delay of probably three to four weeks before we can stop the milk supply from the cows in question. The difficulty of dealing immediately with suspected cows, when the mixed milk from the dairy farm has been found to be tubereulous, greatly minimises at the present time the practical value of bacteriology in this respect. Nevertheless, this work in connection with milk has brought to light the serious extent to which milk is infected with tubercle bacilli, and h a s played its part in hurrying on the shortly expected legislation which wilt doubtless d e a l w i t h tile question at its origin, namely, at the dairy farm. ~ a n y of the dark and insanitary cowsheds must be thoroughly infected with the bacilli given
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o[~ by generations of tuberculous cows, and it is quite conceivable that milk conning from such premises may be infected, not only from any of the diseased cows that are being milked, but also from dust, etc., which happens to be floating about in the cowshed during the milking process. This very probable source of the tubercle bacilli in the dust of the present insanitary cowsheds is often overlooked, and the search for the origin of tile bacitli which have been detected in the mixed supply Dora a dairy farm is too often limited to the cows producing the inilk. In addition to its aid in the foregoing investigations which comprise the greater part of municipal bacteriology, the laboratory will assist us in diagnosing certain diseases of cattle, such as anthrax and tuberculosis, and wi]l he]p ore" enquiries into diseased conditions of food and into outbreaks of food poisoning. I have thus attempted to outline very briefly the chief practical applications of bacteriologT at the present time in public health work. These uses of the science are, of course, well known to all of us, b u t - - a n d this is my chief point--we do not in my opinion sufficiently encourage this branch of our work which, as a matter of fact, is the seientifie basis on which a large part of our sanitary administration rests. In order to adequately make use of bacteriology, each health department should have its own laboratory which should be looked upon as an essential part of the department; and in these laboratories, even in the smaller towns, the necessary investigations should be carried out, except perhaps such as require the inoculation of animals. Unless this obtains, the expense incurred by sending specimens to be examined at some independent laboratory will prevent the extended application of this branch of our work. In the smaller towns, where there may not be sufficient'work for a whole-time bacteriologist, the laboratory can be located at the fever hospital and, if the medical officer of health has not the time to do tlm work himself, the resident at the hospitM or the assistant medical officer of health should also act as bacteriologist. The advantage which the medicM officer of health derives front having a well-equipped laboratory elose at hand, and from his being able to investigate any doubtful ease of infectious disease both clinically and in the laboratory, is evident; and only {,hose
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who thus personally see both sides of the picture can fully appreciate the value of the agglutination reaction or the futility of attempting to diagnose diphtheria without a bacteriological investigation. For the past four or five years, during which I have been connected with infectious disease hospitals, I have made a practice of investigating eases of diphtheria and enteric fever both at the bedside and in the laboratory, and it has ])een a rare occurrence for the bacteriological results to be negatived by the subsequent course of the illness. D u e c a r e must of necessity be exercised in taking the specimens for examination, and carelessness in this procedure will in great part account for many failures in detecting the bacilli in swabbings from throats of diphtheritic patients. Instances, too, where the blood of patients, suffering from apparently typical attacks of typhoid fever, has failed to give the agglutination test with typhoid bacilli, may now be explained on the ground that these were infections b y the b a c i l h s Paratyphosus and not by the bacillus Typhosus, and consequently the blood would have given a positive reaction if tested against the former bacillus. One cannot make a routine examination of diphtheria convalescents without being struck b y the number of eases which continue to harbour the bacilli in their throats for a considerable time longer than three weeks; and when one considers that home treated cases are rarely isolated longer than three weeks, it is evident that we cannot hope to deal satisfactorily with diphtheria so long as the medical practitioner fails to make use of bacteriology to determine the end of infectivity. In like manner, if we are to grapple at all effectively with this disease, we m u s t see that cases of sore throat are more fully investigated and that a routine bacteriological examination of contacts is made. In this paper I have chiefly referred to the pifblic health side of the subject, and especially to the increased protection which would be afforded to the general public by a more extended use of bacteriology. While this aspect of the question is perhaps the one which concerns the medical officer of health the more closely, t h e r e i s also the patient's interest to be considered. Th.erapeutie sera, which at the present day are among our most potent remedies, require for their successful application that an early and definite diagnosis should
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be made, and it is fully proved b y statistics that the administration of antitoxins is the more suecessfill the eai'lier it is undertaken, and that delay in tile use of the remedy carries with it proportional loss for the patient of the advantages offered by this line of treatment. Hence, for this reason also, it is very necessary that means for an innnediate bacteriological examination ef any suspected case should be within easy reach. Then only will the practitioner make full use of the laboratory, and then only shall we be able to complain if he still neglects to avail himself of it. At the present time not only does the general public suffer through being often exposed to the infection of nndiagnosed cases of infectious disease, b u t the patient also suffers front the delay in rec.eiving suitable treatment. We have also a fiehl for work in studying the special germs of our own districts, for doubtless t h e r e are variations of the stone bacillus in different localities, and an antitoxin which is successful against the toxins furnished by the strain of bacillus found in one district may not equally succeed against those of the somewhat modified bacillus flourishing in another part of the country. In m y own experience, for example, diphtheria does not respond to the action of antitoxin in the north of England to the same extent as in the south; and the same difference in the disease is shown by statistics, for while the case mortality rate in the northern towns ranges at about 20 per cent. or more, that for the southern towns averages little over 12 per cent. In' conehsion, I would suggest that, with a little more scientific investigation on the part of the various health departments, many important everyday questions, such as whether drain or sewer air is ever found to convey the germs of diphtheria and typhoid fever, may be more definitely settled, and that we may then be able -to speak from the results of our practical, experiments instead of mereiy expressing pious opinions on the subject. MmWlW~S' ACT UO~t~IITTEE.--The Departmental Committee appointed by the Lord President of the Council to consider the working" of the Midwives' Act, held its sixth meeting on March 10th at the Privy Council Office, Mr. Almerie FitzRoy presiding. The following witnesses :~ttended and gave evidence : Sir George t~ordham, the Treasurer of the Central Midwives Board, and ret)resentative of the County Councils Association; l)r. A. Robinson, Medical Officer of Health for the County Borough of Rotherham ; and Mrs. Heywood Johnstone, President of t,he Rural Midwives Association.